How To Use CPT Code 28289

CPT 28289 describes a surgical procedure used to correct hallux rigidus deformity without the need for an implant. This article will cover the official description, procedure, qualifying circumstances, appropriate usage, documentation requirements, billing guidelines, historical information and billing examples.

1. What is CPT Code 28289?

CPT 28289 is a code used to describe a surgical procedure that corrects hallux rigidus deformity without the use of an implant. Hallux rigidus is a condition characterized by pain and stiffness in the metatarsophalangeal joint of the big toe, caused by arthritis or inflammation. The procedure involves cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint to alleviate pain, improve mobility, and restore function.

2. Official Description

The official description of CPT code 28289 is: ‘Hallux rigidus correction with cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint; without implant.’

3. Procedure

1. The surgeon begins by making an incision over the metatarsophalangeal joint.
2. Through the incision, the surgeon gains access to the joint by dissecting through the soft tissue and retracting the muscles.
3. The joint capsule is incised, allowing entry into the joint.
4. The surgeon examines the joint for any loose bodies or abnormalities and removes them if present.
5. Excessive synovial tissue is debrided to promote better joint function.
6. Bony spurs on the metatarsal head and proximal phalanx are removed using a saw.
7. The eroded joint surface of the metatarsal head is excised.
8. Hemostasis is achieved, and the wound is closed by suturing the soft tissue layers.

4. Qualifying circumstances

CPT 28289 is performed on patients with hallux rigidus, a condition characterized by arthritis or inflammation in the metatarsophalangeal joint of the big toe. The procedure is indicated when conservative treatments have failed to alleviate pain and improve mobility. It is important to note that this procedure does not involve the use of an implant.

5. When to use CPT code 28289

CPT code 28289 should be used when a surgeon performs a hallux rigidus correction procedure without the use of an implant. It is appropriate when the surgeon performs cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint to address the hallux rigidus deformity. If an implant is used during the procedure, a different CPT code should be used to accurately reflect the surgical technique.

6. Documentation requirements

To support a claim for CPT code 28289, the surgeon must document the following information:

• Patient’s diagnosis of hallux rigidus and the need for surgical correction
• Description of the procedure performed, including cheilectomy, debridement, and capsular release
• Date of the procedure
• Details of any complications or unexpected findings during the procedure
• Post-operative care instructions and follow-up plans
• Signature of the surgeon performing the procedure

7. Billing guidelines

When billing for CPT code 28289, ensure that the procedure performed aligns with the official description. It is important to accurately document the surgical technique and any additional procedures performed during the same operative session. Review the range of codes from 28200 to 28360 to ensure accurate coding for bunion correction procedures. It is also important to follow any specific guidelines provided by the payer or coding guidelines to ensure proper reimbursement.

8. Historical information

CPT code 28289 was added to the Current Procedural Terminology system on January 1, 1999. The code has undergone changes, with the most recent update occurring on January 1, 2017, when the description was revised to include specific details about the procedure.

9. Examples

1. A patient with hallux rigidus undergoes a surgical procedure to correct the deformity without the use of an implant.
2. A surgeon performs cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint to address hallux rigidus in a different patient.
3. Another patient with hallux rigidus undergoes a similar procedure to alleviate pain and improve mobility.
4. A surgeon performs a hallux rigidus correction procedure without an implant in a patient with advanced arthritis in the metatarsophalangeal joint.
5. Yet another patient with hallux rigidus undergoes a surgical procedure to restore function and alleviate pain in the affected joint.
6. A surgeon performs cheilectomy, debridement, and capsular release of the first metatarsophalangeal joint in a patient with hallux rigidus deformity.
7. Another patient with hallux rigidus undergoes a similar surgical procedure to improve mobility and reduce pain.
8. A surgeon corrects hallux rigidus deformity without an implant in a patient who has been experiencing significant pain and stiffness in the metatarsophalangeal joint.
9. Yet another patient with hallux rigidus undergoes a surgical procedure to address the deformity and improve joint function.